Module 7: Errors in transfusion

1. Module 7: Errors in transfusion Transfusion Training Workshop KKM 2012

2. Sources of Error

3. Case 1 • 60 year-old man, hospital RN 721677 • Post-BKA • Hb 7 g/dL • 2 PC requested

4. Case 1 – cont’d • Sample and request form arrived at BB • BB staff checked sample and request form • Sample had a different patient’s name, IC and RN no.

5. Case 1 – cont’d • Patient requiring GXM • 60 year-old man • Orthopedic ward 5C • Name: Mr YKC • Label on sample • 28 year-old lady • Maternity ward 4D • Name: Mrs KB

6. Case 1 – what happened… • Patient requiring GXM • 60 year-old man • Orthopedic ward 5C • Name: Mr YKF • RN 721677 • Blood group O • Label on sample • 28 year-old lady • Maternity ward 4D • Name: Mrs SW • RN 721667 • Blood group AB

7. Always make sure the sample is labeled for the right patient AT THE BEDSIDE with at least 2 patient identifiers Name IC no

8. Best practice 1 • Identify and inform patient • Draw blood sample • Label sample by handwriting at bedside • Collect or print sticker label • Check printed label matches handwritten details before pasting on sample tube

9. Best practice 2 • Print the patient’s sticker label • Identify correct patient • Inform patient (the need for transfusion) • Draw blood sample • Check label with patient • Stick label (at bedside)

10. Case 2 • B/O RR, premature infant @ 27 weeks • Day 13 OL on ventilator • 14th April 2011 @ 1235h: received GXM request • Grouped as AB Rh pos • Previous record: group O Rh positive • Re-grouping with second sample: AB Rh pos

11. Case 2 – cont’d • Possible explanation: 1st grouping was wrong • So BB staff went up to the ward • Bedside grouping: group O Rh positive • So what happened?

12. Case 2 – cont’d • What actually happened: • 1st sample: • Doctor A took blood sample • Doctor B labeled the sample • Doctor C filled and signed the request form • 2nd sample: • Doctor D took an unlabeled sample from the fridge and sent to BB

13. The SAME doctor or staff who draws the blood sample must also label it At the bedside

14. Just imagine if there was no previous record and this was a new patient If this was an older child, he would have been transfused with AB blood when he is actually group O!

15. Case 3 • 28th March 2011: received a GSH sample for Supramaniam A/L Kannan • Grouped as A Rh pos • Previous record: Group O Rh pos • So what went wrong?

16. Case 3 – cont’d • There were 2 patients with the same first name in the ward • Supramaniam A/L Kannan Bed 16 • Supramaniam A/L Solamalai Bed 23 • Bedside grouping • Patient 1: Group O Rh pos • Patient 2: Group A Rh pos

17. Case 3 – cont’d • What went wrong: • Doctor A: filled the request form • Doctor B: drew the blood sample from the wrong patient • Doctor A: labeled the sample

18. How do we prevent errors? Correct practice at every step

19. Step 1: the decision to transfuse • Avoid inappropriate and unnecessary transfusions • Inform patient • Fill up request form • Ask patient for blood group if known

20. Step 2: correct patient identification (prior to blood sampling) • Ask the patient his/ her full name and identification card no. (DOB and MRN) • Check the wrist band (in-patient) or hospital card/ ic (daycare)

21. Step 3: blood sampling • NEVER pre-label GXM tubes (EDTA) • The SAME doctor/ staff must take blood sample and label the tube • NEVER use pre-printed labels • Show labeled tube and completed request form to patient • NEVER take blood samples from >1 patient at a time

22. A B D C

23. Step 4: receipt of blood request • BB staff must • make sure sample and request form are properly and correctly labeled • check for any previous transfusion record

24. Step 5: collection of blood • Bring collection slip and blood box • BB staff must check collection slip matches request form and blood to be collected • Withdrawal of units must be documented • Staff name • Date • Time issued • Inspect colour and expiry date

25. Collection slip Blood box ± ice

26. INSPECT – accept or reject? Bacterially contaminated platelets Clotted red cell

27. Step 6: correct patient identification at bedside (prior to transfusion) • Conscious patient • Ask patient’s full name and ic no. • Check against wrist band • Ask for blood group type if known • Check patient ID, form, blood unit and PPDK card matches • Unconscious patient • Check wrist band • Check patient’s notes/ IC • Check patient ID, form, blood unit and PPDK card matches • Double check by second person

28. Bedside check

29. Step 7: monitoring vital signs • Transfuse blood/ components promptly (after correct bedside patient identification) • Check T0, BP and PR prior to transfusion • Re-check vital signs first 15 minutes and ½-1 hourly • Fill PPDK card AFTER completion of transfusion • Return PPDK card with used blood bags to BB

30. Monitoring vital signs • Prior to transfusion • Periodically thereafter

31. Correct practice at every step from vein to vein Ensures a safe transfusion

32. Vein to vein

33. But what happens when this practice fails? NEAR MISSES - you’re lucky MEDICO-LEGAL CASES - no way out

34. Medico-legal issues

35. Wrong blood – wrong patient • The single most frequent error resulting in ABO-incompatible transfusion is the administration of properly labeled blood to a recipient other than the one intended Linden JV, 1993

36. Case 4 • 50 year-old lady • c/o menorrhagia x 2 years • Hb 5.6 • Film: iron deficiency anaemia • Diagnosis: • Menorrhagia 20 to DUB with chronic anaemia

37. Case 4 – cont’d • O/E: Pale Koilonychia • BP 140/85 PR 78 • Chest: clear • No pedal oedema

38. Case 4 – cont’d • GXM 3 PC requested • 2 PC transfused on night of 5th April 2007- uneventful • 3rd PC commenced at 0400 on 6th April 2007 • After 200mls, c/o headache, breathlessness, nausea and vomiting

39. Case 4 – cont’d • Blood transfusion stopped • Transferred to ICU • O/E: pale and tachypnoeic • BP 116/68 PR 98 T 400C PO2 75 mmHg • No urine output

40. Case 4 – cont’d • Diagnosis: • Acute haemolytic transfusion reaction • Acute oliguric renal failure • Acute respiratory distress • Disseminated intravascular coagulation

41. Case 4 – cont’d • Management • Ventilatory support • Renal support with haemodialysis • Blood support • 13 units PC • 24 units cryo • 15 units FFP • 26 random and 3 apheresis platelets = 81 donor exposures + 3 (PRBC)

42. Case 4 – cont’d • Patient survived • Discharged on 27th April 2007 • On follow-up 1 year later, mild renal impairment and hypertension • No more menorrhagia

43. Case 4 – how error happened • HO checked blood and request form at nurses counter • 2 patients requiring blood at the same time • HO ticked ✓ and signed checklist form at counter

44. Case 4 – how error happened • No bedside check done • Nurse in charge did not double check • Patient group O given A blood, the other patient group A given O blood

45. The verdict – medical negligence Case awarded a substantial amount

46. In the news… Contaminated blood

47. Case 1 Wednesday November 14, 2007 Ex-teacher awarded RM450,000 By EMBUN MAJID ALOR STAR: A former Quran teacher, who sued the Government over the HIV-contaminated blood she received during a transfusion seven years ago at Jitra Hospital, has been awarded RM450,000.

48. Case 2 SEGAMAT, JOHOR: Felda settler Norizan Ismail died last Friday, four years after allegedly contracting HIV in hospital. Norizan, 46, of Felda Palong Timur, is believed to have been infected with HIV during a blood transfusion at Segamat District Hospital. She was later diagnosed HIV-positive.

49. But …

50. Major risks of transfusion • The major risks of transfusion currently lie in the clinical use of blood in hospitals, rather than with transmission of infectious agents through the supply Stephen Review 2001